ORIGINAL ARTICLE

Int Health 2015; 7: 420425

doi:10.1093/inthealth/ihv021 Advance Access publication 8 April 2015

Knowledge, attitude and preventive practices regarding

dengue fever in rural areas of Yemen
Khaled G. Saieda,*, Abdullah Al-Taiarb, Abdulrahman Altairea, Ala Alqadsia,
Enas F. Alariqia and Maha Hassaana
a

*Corresponding author: Tel: +967 713262611; E-mail: kghilan@yahoo.co.uk

Received 12 October 2014; revised 20 February 2015; accepted 16 March 2015

Background: In recent years there have been several reports of outbreaks of dengue fever (DF) in Yemen. This
study aimed to describe the prevailing knowledge, attitude and preventive practices regarding DF, and to investigate the factors associated with poor preventive practices in rural areas of Yemen.
Methods: A population-based, cross-sectional study was conducted on 804 randomly selected heads of household. A pretested, structured questionnaire was administered through face-to-face interviews. Logistic regression
was used to investigate factors independently associated with poor practice.
Results: Out of 804 participants, 753 (93.7%) were aware of the symptoms of DF and 671 (83.4%) knew that DF
was transmitted by mosquito bites. Only 420 (52.2%) knew that direct person-to-person transmission was not
possible. Furthermore, 205 (25.5%) thought that someone with DF should be avoided and 460 (57.2%)
thought the elimination of breeding sites was the responsibility of health authorities. Poor knowledge of DF
and a low level of education were signicantly associated with poor preventive practices.
Conclusions: In rural areas of Yemen, people have a vague understanding of DF transmission and a negative
attitude towards preventative practices. Efforts should be made to correct misconceptions about transmission
of the disease and to highlight the importance of community participation in control activities.
Keywords: Attitude, Dengue, Knowledge, Practices, Yemen

Introduction
Dengue fever (DF) is a mosquito-borne viral infection that has recently
become a major international public health concern. Over the past
ve decades, there has been a dramatic global increase in the incidence of DF1 and the disease has become now endemic in more
than 125 countries.2 It has been estimated that annually 96
million new apparent infections occur worldwide, with 294 million
inapparent infections.3 These unobservable infections create enormous difculty in terms of understanding the true economic
burden of the disease and the dynamics of the infection. Despite
some progress in vaccine development, there are none readily available on the market as well as no specic treatment for DF. Thus, the
most effective way to prevent dengue virus transmission is to
combat disease-carrying mosquitoes, particularly Aedes aegypti
and A. albopictus.
Recent DF outbreaks have been reported from within WHOs
eastern Mediterranean Region in Sudan, Saudi Arabia and Yemen.
Unlike its oil-rich neighbouring countries, Yemen has weaker

healthcare and surveillance systems. Recently, frequent DF outbreaks have been reported in the media, few of which have been
properly documented.4,5 During these outbreaks, the predominant
serotype was type 2 in the west6 and type 3 in the southeast.4,5
Mostly young adults were affected. Among the suspected cases in
the southeast, studies have reported a high prevalence of dengue
IgG suggesting previous exposure and background endemicity preceding these outbreaks.4 Overall, the true burden of the disease in
Yemen remains unknown, but is anticipated to be high.
The knowledge and attitude of the general public towards DF
have been recently described in various settings,714 but little is
known about them in Yemen or the Middle East. Previously, we
demonstrated that people in Yemen have a vague understanding
of the causes of malaria. While the majority of people know that
malaria is caused by mosquito bites, most believe that malaria
can also be caused or transmitted by a range of factors, including
ies, eating uncovered food, not having breakfast and breastfeeding.15 In this study, we aimed to describe the knowledge, attitude
and preventive practices regarding DF, using a population-based

The Author 2015. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved.
For permissions, please e-mail: journals.permissions@oup.com.

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Department of Community Medicine, Faculty of Medicine and Health Sciences, Sanaa University, P.O. Box 2583 Al-Tahreer Post Ofce,
Sanaa, Yemen; bDepartment Community Medicine and Behavioural Sciences, Faculty of Medicine, Kuwait University, Box 24923 Safat,
13110 Kuwait, Kuwait

International Health

survey in one rural district of Yemen, and to investigate the factors

associated with poor preventive practices.

Methods

Table 1. Socio-demographic characteristics of 804 head of

households in Hodeidah, Yemen
Characteristics

n (%)

Age, median (IQR) years

Gender, male
Marital status
Married
Single
Widowed/divorced
Working in paid job
Educational level
Illiterate
Able to read and write
Completed primary school
Completed intermediate school
Completed secondary school
Completed university degree or more

39 (3050)
741 (92.2)
665 (82.7)
104 (12.9)
35 (4.4)
386 (48.0)
442 (54.9)
80 (10.0)
100 (12.4)
71 (8.8)
80 (10.0)
31 (3.9)

Results
Of the 820 heads of household approached, 16 (1.9%) refused to
participate. Table 1 shows the characteristics of the study group.
The median (interquartile range [IQR]) age was 39 (IQR 3050)
years. Of the participants, 741 (92.2%) were men and 665
(82.7%) were married. More than half of the members of study
group were illiterate (54.9%; 442/804) and 3.9% had a university
degree (31/804).
The number of those demonstrating the correct knowledge
about DF among the study group is shown in Table 2. Of 804
heads of household, 753 (93.7%; 95% CI 91.795.2%) knew
that the main symptoms of DF are fever, headache, pain behind
the eyes, joint pain, muscle pain and skin rash. Six hundred and
ve (75.2%; 95% CI 72.178.2%) knew that abdominal pain,
vomiting blood, bloody stools and bleeding from the nose were
signs of severe DF. More than three quarters, 671 (83.4%; 95%
CI 80.786.0%), knew that DF was transmitted by mosquito
bites, but only 420 (52.2%; 95% CI 48.755.7%) knew that DF
cannot be transmitted from an infected person to a healthy
person through direct contact.
Positive and negative attitudes towards DF are shown in Table 3.
Of the study participants, 528 (65.7%; 95% CI 62.369.0%) agreed
that DF is a serious and sometimes life-threatening disease, and
685 (85.2%; 95% CI 82.687.6%) agreed that sleeping under a
bed net can help to prevent it. Of 804 heads of household, 205
(25.5%; 95% CI 22.528.6%) thought that close contact with a
person with DF should be avoided. Of even more concern was the
fact that 460 (57.2%; 95% CI 53.760.7%) thought the elimination
of breeding sites should be the responsibility of health authority
staff only. Surprisingly, more than 41.0% either agreed that DF
cannot be prevented, or were not sure whether it can be prevented.
Those among the study group who reported correct DF preventive practices are shown in Table 4. Of 780 participants who reported
owning water tanks, 730 (93.5%; 95% CI 91.695.2%) had covers

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A cross-sectional study was conducted in the Beit Al-fakieh district

of Hodeidah province, which is located along the west coast of
Yemen on the Red Sea. The area comprises eight sub-districts. It
has two rainy seasons (November-March and June-October)
and had a high occurrence of DF in 2011.16 The study population
comprised the heads of households who had lived in the district
for at least 1 year. Those who were not able to communicate
because of mental illness or severe hearing defects were
excluded. We used a multistage random sampling to select the
study group. First, we randomly selected two sub-districts from
the eight sub-districts. We then randomly selected ve villages
from the two selected sub-districts according to the relative size
of the population in the sub-district. In each village, the households were selected in a systematic random sampling method
taking the rst house in the centre of the village as a random start.
Data were collected through face-to-face interviews, with the
heads of the households using a structured, pretested questionnaire. This included questions on socio-demographic characteristics such as age, gender, marital status and educational level in
addition to questions on knowledge about DF. This part of the
questionnaire included 14 questions (requiring yes, no or do
not know answers) related to signs and symptoms, transmission,
treatment and prevention. Attitudes towards DF were measured
using 12 statements (requiring agree, disagree or not sure/do
not know answers), which covered susceptibility, seriousness
and threat. Practices regarding DF were assessed by 12 items covering various aspects of prevention. The questionnaire was piloted
on 30 participants who were not included in the study.
The data were entered and analysed using SPSS software
version 20 (SPSS Inc., Chicago, IL, USA). The total score of knowledge about DF was calculated by assigning one score for each
correct answer and zero score for each wrong answer. These

were then summed up to calculate the total score of knowledge.

Similarly, in order to calculate the attitude score, the answers
agree, not sure and disagree were given scores of 3, 2 and 1,
respectively (the scores were reversed for negative attitude
items) and these were added to calculate the total score. A
similar approach was used to calculate the practice score, with
zero score assigned to each wrong practice and one score assigned
to each correct practice. Respondents who scored more than the
median value (11 for knowledge, 29 for attitudes, 6 for practice)
were considered to have good levels of knowledge, attitude and
practices, while those who scored the median value or less were
considered to have poor levels. Spearmans correlation coefcient
was used to assess the strength and direction of the bivariate relationship between knowledge, attitude and practices dealing with
scores as a continuous variable. Logistic regression was used to investigate the independent factors associated with poor preventive
practices. The signicance of each variable was determined using a
likelihood ratio test that compared the model with and without the
variable.
The study was approved by the Faculty of Medicine and Health
Sciences of Sanaa University, and verbal consent was obtained
from each participant after adequate explanation of the nature
of the study.

K. G. Saied et al.

Table 2. Correct knowledge about dengue fever among 804 head of households in Hodeidah, Yemen
n (%)

Patient with dengue fever usually has fever, headache, pain behind the eyes,joint pain, muscle pain and skin rash
Abdominal pain, vomiting blood, bloody stools, bleeding from nose are signs of danger in dengue fever
Dengue fever may affect children and adults
Dengue fever is transmitted by mosquito bites
Mosquitoes that transmit dengue fever bite mainly during the daytime
Dengue fever is not transmitted from an infected person to a healthy person through direct contact
The main method of controlling dengue fever is to combat mosquitoes
Stagnant water in old tyres and trash cans can be breeding places for mosquitoes
Dengue fever is more common in the rainy season
Uncovered water containers should be cleaned every week
Water containers in the house are the most common breeding sites of mosquitoes
Discarded tyres and tin cans should be eliminated to prevent dengue fever
Covering water collections around the house with sand is one ways to combat mosquitoes
There is no specic treatment for dengue fever

753 (93.7)
605 (75.2)
766 (95.3)
671 (83.5)
270 (33.6)
420 (52.2)
638 (79.4)
692 (86.1)
683 (85.0)
654 (81.3)
611 (76.0)
617 (76.7)
633 (78.7)
347 (43.2)

Table 3. Distribution of the respondents attitudes towards dengue fever (n=804)

The statements

Agree
n (%)

Disagree
n (%)

Not sure
n (%)

Dengue fever is a serious and sometimes life-threatening diseasea

Everybody can be infected with dengue fevera
Sleeping under a bed net can help prevent dengue fevera
You have an important role in the prevention of dengue fevera
The best way to prevent people from getting dengue fever is to control mosquitoesa
If someone gets dengue fever, she/he should seek treatmenta
The risk of getting dengue fever among men and women is not the sameb
A person who once had dengue fever cannot get it againb
Close contact with people with dengue fever should be avoidedb
Strong, healthy people do not get dengue feverb
Dengue fever is a disease that cannot be preventedb
Elimination of breeding places is the responsibility of public health staff onlyb

528 (65.7)
726 (90.3)
685 (85.2)
604 (75.1)
676 (84.1)
678 (84.3)
169 (21.0)
137 (17.0)
205 (25.5)
170 (21.1)
157 (19.5)
460 (57.2)

71 (8.8)
26 (3.2)
32 (4.0)
132 (16.4)
23 (2.9)
19 (2.4)
449 (55.8)
474 (59.0)
492 (61.2)
499 (62.1)
473 (58.8)
274 (34.1)

205 (25.5)
52 (6.5)
87 (10.8)
68 (8.5)
105 (13.1)
107 (13.3)
186 (23.1)
193 (24.0)
107 (13.3)
135 (16.8)
174 (21.6)
70 (8.7)

a
b

Positive statement where agree is the correct answer.

Negative statement where disagree is the correct answer.

for them, and almost all said that they covered them immediately
after use. Only a minority reported using preventive measures
against mosquitoes, such as mosquito nets (131/804; 16.3%;
95% CI 13.819.0%), window screens (59/804; 7.3%; 95% CI
5.69.4%) or door screens (65/804; 8.1%; 95% CI 6.310.2%),
but more than one-third said that they spray insecticide indoors
or use repellent to prevent mosquito bites. Approximately 94%
(755/804) said that they sought medical help when they felt sick.
Logistic regression was used to investigate the factors signicantly associated with poor DF preventive practices. The binary outcome
for this analysis was created by dichotomising the practice score into
good (> median) and poor ( median). Tables 5 and 6 show the
association between different factors and poor preventive practices

422

using univariate and multivariate analyses. Factors that showed a

signicant association with poor practice in the univariate analysis
were older age, low educational level, not working in a paid job,
fewer people in the house and poor knowledge of and attitudes
towards DF. In the multivariate analysis, only low educational level
and poor knowledge of DF were signicantly related to poor preventive practices. A Spearmans rank order correlation was used to investigate the link between the knowledge, attitude and preventive
practices scores. There was a weak positive correlation between
the knowledge and attitude scores, between the knowledge and
preventive practices scores and between the attitude and preventive
practices scores (the Spearmans correlation coefcient was 0.234
[p<0.001], 0.192 [p<0.001] and 0.150 [p<0.001], respectively).

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Correct knowledge answers

International Health

Table 4. Distribution of reported correct preventive practices against dengue fever among 804 heads of households in Hodeidah, Yemen
n (%)

Do you have a cover for all your water tanks (water containers)?
Do you cover your water tank immediately after using it?
Do you eliminate stagnant water around your house to reduce mosquitoes?
Do you get rid of discarded tyres and tin cans which contain stagnant water?
Do you use mosquito nets to prevent mosquito bites?
Do you have window screens to reduce mosquitoes?
Do you have a door screen to reduce mosquitoes?
Do you spray insecticides indoor to reduce mosquitoes?
Do you use repellent for mosquitoes?
Do you cut the trees/vegetation surrounding your house to reduce mosquitoes?
Do you participate in campaigns to help prevent dengue fever in your community?
Do you usually go to the health centre/unit when you feel ill?

730a (93.5)
728a (93.3)
536 (66.7)
505 (62.8)
131 (16.3)
59 (7.3)
65 (8.1)
290 (36.1)
320 (39.8)
400 (49.8)
336 (41.8)
755 (93.9)

Of 804 participants, 24 (3.0%) did not store water at home (those without water tanks).

Discussion
Table 5. Socio-demographic factors, knowledge and attitudes
regarding dengue fever in relation to poor preventive practices (
the median score) using univariate analysis

Age in years
Gender
Male
Marital status
Married
Divorced/widowed
Single
Education level
Illiterate
Able to read and write
Primary/intermediate
High school or above
Working
No
Number of people in house
<6
710
>10
Knowledge score
Poorb
Goodc
Attitude score
Poorb
Goodc
a

OR

95% CI

p-value

804

1.02

1.011.03

<0.001

741

1.22

0.722.07

0.451
0.095

665
35
104

1.18
2.60
1.00

0.771.80
1.046.51
NAa

442
80
171
111

3.77
2.63
1.28
1.00

2.455.81
1.444.78
0.792.07
NAa

418

1.50

1.122.01

262
421
117

1.64
1.64
1.00

1.052.56
1.082.49
NAa

549
255

1.76
1.00

1.302.39
NAa

482
322

1.51
1.00

1.122.02
NAa

<0.001

0.006
0.050

<0.001

0.006

NA: not applicable, reference group.

Less than or equal to the median.
c
More than the median.
b

Even before the current social upheaval, the healthcare system in

Yemen was unable to detect and respond to outbreaks of infectious diseases such as DF. As the current social unrest will compound the difculty in preparedness and response to epidemics,
and it would therefore seem sensible for public health initiatives
to capitalise on the knowledge and behaviour of the general population in order to prevent the disease, rather than to rely on governmental responses. However, despite many reports of recent DF
epidemics, the general populations knowledge, attitude and preventive practices regarding DF remain mostly unknown in Yemen
and the broader Middle East. We have demonstrated that people
in rural areas of Yemen have a vague understanding of DF transmission and many of them believe the health authority to be
responsible for controlling mosquitoes. We have also demonstrated that knowledge and preventive practices are linked.
The majority of participants in the study were aware of the
symptoms of DF, which include fever, headache, pain behind the
eyes, joint pain, muscle pain and skin rash. These ndings are
similar to those reported in a study in Nepal, although that study
found knowledge levels to be lower in highland areas.8 More than
three-quarters of the participants in the present study agreed
that abdominal pain, vomiting blood, bloody stools and bleeding
from the nose were signs of severe DF. People become more knowledgeable about the signs and symptoms of the disease when they
live in communities with a high prevalence,17 and this may explain
the good levels of knowledge about the signs and symptoms of DF
in our setting. Such good knowledge about the symptoms of DF is
likely to be useful in health-seeking behaviour.
In this study, the majority of the participants (83%) agreed
that DF is transmitted by mosquito bites. This is a similar result
to that reported among people visiting tertiary care hospitals in
Pakistan.18 However, only one-third of the study participants
thought that transmission can occur during the daytime. This is
probably because the study area is endemic with malaria and
thus people are more familiar with the A. arabiensis vector that

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Correct practices

K. G. Saied et al.

Table 6. Factors associated with poor preventive practices against

dengue fever ( the median score) using multivariate analysis
95% CI

3.80
2.78
1.32
1.00

2.455.86
1.525.10
0.812.14
NAa

1.73
1.00

1.262.38
NAa

p-value
<0.001

<0.001

NA: not applicable, reference group.

Less than or equal to the median.
c
More than the median.
b

is generally active during the night, whereas the dengue vectors

are generally active before dusk.19,20 We have previously demonstrated that, although the majority of people link malaria to mosquitoes, the quality of their knowledge of the disease transmission
is undermined by various misconceptions, such as the belief in
transmission of the disease by ies, breast milk or through
person-to-person contact.15 In the present study, half of the
study group thought the disease can be transmitted from an
infected person to a healthy person through direct contact
(Table 2). A recent study in Nepal reported that, of 589 participants, 32% believe DF to be transmitted by ies, 42% by ticks,
51% through food and water and 56% through person-to-person
contact.8 Similar ndings have been reported from Jamaica,
where, of 188 residents, 33% and 28% believe DF to be transmitted by ies and ticks, respectively.21 Such misconceptions may
lead to the assumption that DF is an unavoidable disease for
local people because, as from the local perspective, avoidance
of mosquitoes alone is not sufcient to prevent the disease. This
might explain why more than 40% of the participants in our
study reported believing that DF is a disease that cannot be prevented, or were not sure whether it can be prevented (Table 3).
In Nepal, however, despite these prevalent misconceptions,
95% of the participants agreed that DF can be prevented,
although the authors attribute this to the cultural context that
mean that people in that area have a tendency to agree with
the statements that investigators use to measure attitude.8
Overall, the majority of participants had an unfavourable attitude towards various aspects of the disease, and a large number
had a negative attitude towards disease prevention in comparison
with those in Asian settings.8,22,23 As mentioned above, such variance may be attributed to differing cultural contexts, but this does
not preclude the public health implications of the results. It is a
major concern that 57% of the participants thought that the elimination of breeding sites is the sole responsibility of the health
authorities. Given the current social unrest in the country, health
authorities are unlikely to be able to eliminate breeding sites,
and educational campaigns should therefore stress the importance of community participation and promote the role of individuals in controlling DF by reducing breeding sites in and around

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Education level
Illiterate
Able to read and write
Primary/intermediate
High school or above
Knowledge score
Poorb
Goodc

OR

their homes. As mentioned above, 40% of the study group

thought the disease cannot be prevented or were not sure
whether it can be prevented. While such beliefs may be attributed
to local misconceptions about the multiple causes of DF, they may
also be due to experience of frequent outbreaks of the disease. A
study in Malaysia has demonstrated that communities with high
IgG seropositivity (which reects high frequency of DF) usually
report a general lack of self-efcacy in taking preventive measures
against DF.7 Such communities are also highly likely to report a
lack of preventive measures at the community and authority
level.7
A lack of tap water forces people to store water in their households, which increases the risk of DF.7 In the study area, there is
no tap water supply and 97% of households have water tanks.
Although most participants reported covering their water tanks
after use, this situation makes community engagement in elimination of mosquito breeding sites in water containers highly
important. As in other areas of Yemen, the use of mosquito nets
seems to be a rare practice;24 when they are used, it is generally
only to help babies sleep without being disturbed by ies.15 It
appears that mosquito nets, window and door screens and
other preventive measures are used less in rural areas of Yemen
than in other settings.8,21
In this study, both univariate and multivariate analyses
revealed an association between knowledge and preventive practices. These results are similar to those reported from Laos22 and
Nepal,8 but differ from those reported in Malaysia,23 Jamaica21
and Thailand,17 where good knowledge levels did not lead to
good preventive practices. However, the association in our study
was not strong, which may support the notion that knowledge
does not necessarily correspond to preventive measures. It is
also not clear from this study whether self-reported practices correspond with actual preventive practices. In Thailand, for instance,
respondents with a good knowledge of preventive measures are
more likely to have a higher number of unprotected containers
in and around their houses;17 while in Malaysia self-reported practices are signicantly associated with seropositivity in univariate
but not in multivariate analyses.7 In our setting, low educational
levels and poor knowledge of the disease were the main predictors of poor preventive practices against DF (Table 6). A study on
a convenient sample of people attending tertiary care hospitals
in Pakistan, showed income as the only predictor of good knowledge about DF in multivariate analysis.18 In our setting, income
data was not collected because less than half of the participants
were in paid work, and education, independent of knowledge, was
found to be signicantly related to preventive practices. In fact no
association was found between the knowledge score and the
educational level (data not shown).
This is the rst study that has systematically investigated the
knowledge, attitude and preventive practices regarding DF in
Yemen, from where WHO has received reports of several recent
outbreaks. We chose to conduct a household survey via personal
interviews because of the high illiteracy rate. The response rate
was high and the ndings are thus critical to guiding public
health initiatives and encouraging community participation. One
of the weaknesses of our study was that we did not inspect the
breeding sites around the houses. However, it would have been
difcult to standardise such an observation, which, in any case,
may only have provided a snap-shot of the situation. The target
population (heads of households) were primarily men with

International Health

whom decisions about taking preventive measures were likely to

rest, and so our ndings cannot be extrapolated to other groups
in the community, such as mothers. Finally, this type of study is
useful for gathering information on knowledge, attitude and practices pertaining to a health issue but the interpretation of the
results should take into account the cultural context of the local
population, an understanding of which could be acquired
through qualitative research.

5 Madani TA, Abuelzein el TM, Al-Bar HM et al. Outbreak of viral

hemorrhagic fever caused by dengue virus type 3 in Al-Mukalla,
Yemen. BMC Infect Dis 2013;13:136.

Conclusions

8 Dhimal M, Aryal KK, Dhimal ML et al. Knowledge, attitude and practice

regarding dengue fever among the healthy population of highland and
lowland communities in Central Nepal. PLoS One 2014;9:e102028.

7 Wong LP, AbuBakar S, Chinna K. Community knowledge, health beliefs,

practices and experiences related to dengue fever and its association
with IgG seropositivity. PLoS Negl Trop Dis 2014;8:e2789.

9 Bota R, Ahmed M, Jamali MS, Aziz A. Knowledge, attitude and

perception regarding dengue fever among university students of
interior Sindh. J Infect Public Health 2014;7:21823.
10 Wong LP, AbuBakar S. Health beliefs and practices related to dengue
fever: a focus group study. PLoS Negl Trop Dis 2013;7:e2310.
11 Chanyasanha C, Han MM, Teetipsatit S. Dengue hemorrhagic fever
knowledge, perception, and preventive behavior among secondary
school students in Bangkok. J Med Assoc Thai 2013;96 (Suppl 5):S1424.
12 Al-Dubai SA, Ganasegeran K, Mohanad Rahman A et al. Factors
affecting dengue fever knowledge, attitudes and practices among
selected urban, semi-urban and rural communities in Malaysia.
Southeast Asian J Trop Med Public Health 2013;44:3749.
13 Flynn A. A study exploring the knowledge, attitudes and practices of
young people regarding dengue fever and the extent of community
involvement in vector control of the disease in Trinidad and Tobago.
West Indian Med J 2012;61:6158.
14 Fajardo-Dolci G, Meljem-Moctezuma J, Vicente-Gonzalez E et al. The
dengue fever in Mexico. Knowledge for improving the quality in
health [in Spanish]. Rev Med Inst Mex Seguro Soc 2012;50:6319.

Authors contributions: KGS, AAT conceived the study, analysed the data
and drafted the manuscript; AAL, AAQ, EAL, MHA collected the data and
revised the manuscript for intellectual content. All authors read and
approved the nal manuscript. KGS is the guarantor of the paper.

15 Al-Taiar A, Chandler C, Al Eryani S, Whitty CJ. Knowledge and practices

for preventing severe malaria in Yemen: the importance of gender in
planning policy. Health Policy Plan 2009;24:42837.

Acknowledgments: We are grateful to all the participants in the study. We

are grateful to Manal Q. Alariqi, Ahmed Almaasali, Solaf Alwadhi, Hashem
Alkibsi, Yehya Alsabri and Areej Alsiaghy for their contributions to this
study. We are also grateful to Professor Saeed Akhtar, Dr Lukman Thalib
and Dr Reem Al-Sabah for their comments on the draft of this manuscript.

17 Koenraadt CJ, Tuiten W, Sithiprasasna R et al. Dengue knowledge and

practices and their impact on Aedes aegypti populations in
Kamphaeng Phet, Thailand. Am J Trop Med Hyg 2006;74:692700.

Funding: None.
Competing interests: None declared.

16 MPHP. Malaria Control Project Report. Yemen: Ministry of Public Health

and Population; 2011.

18 Itrat A, Khan A, Javaid S et al. Knowledge, awareness and practices

regarding dengue fever among the adult population of dengue hit
cosmopolitan. PLoS One 2008;3:e2620.
19 Yasuno M, Tonn RJ. A study of biting habits of Aedes aegypti in Bangkok,
Thailand. Bull World Health Organ 1970;43:31925.

Ethical approval: The study was approved by the Faculty of Medicine and
Health Sciences of Sanaa University.

20 Boorman J. Studies on the biting habits of the mosquito Aedes

(Stegomyia) aegypti, Linn., in a West African village. West Afr Med J
1960;9:11122.

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In summary, we have demonstrated that people in rural areas of

Yemen have a vague understanding of the transmission of DF,
their attitudes towards various aspects of the disease are negative
and they rarely undertake preventive practices against the
disease. Public education is needed to correct the misconceptions
that there are other methods of transmission, such as direct
contact with an infected person, so that it becomes clear that preventing mosquito bites is sufcient to prevent DF. The educational
message should be simple in order to accommodate the high
rates of illiteracy in the community. Efforts should be made to
encourage the use of bed nets, which is strikingly low. Educational
campaigns should also focus on the role of the community participation in order to correct the belief that the elimination of DF is the
sole responsibility of health authorities. Community participation
is critical given the current social unrest in the country and in
the light of the fact that frontline health services are fairly poor
and unlikely to distinguish DF from other infectious diseases.

6 Rezza G, El-Sawaf G, Faggioni G et al. Co-circulation of Dengue and

Chikungunya Viruses, Al Hudaydah, Yemen, 2012. Emerg Infect Dis
2014;20:13514.